What is the recommended dose of epinephrine (adrenaline) for pediatric patients?

Epinephrine Dosing for Pediatric Patients

For anaphylaxis, administer epinephrine 0.01 mg/kg (maximum 0.3 mg for children, 0.5 mg for adolescents/adults) intramuscularly into the anterolateral thigh using 1:1000 concentration, repeated every 5-15 minutes as needed. 1, 2, 3

Anaphylaxis Management

First-Line Intramuscular Dosing

• Inject 0.01 mg/kg of 1:1000 epinephrine solution intramuscularly into the mid-outer thigh (vastus lateralis) immediately upon recognizing anaphylaxis 1, 2, 3
• Maximum single dose: 0.3 mg for children <30 kg, 0.5 mg for children ≥30 kg and adults 3
• The intramuscular route in the lateral thigh achieves peak plasma concentration in 8±2 minutes versus 34±14 minutes with subcutaneous injection 1, 4
• Repeat every 5-15 minutes if symptoms persist or recur 1, 2, 3
• Approximately 6-19% of pediatric patients require a second dose 1

Autoinjector Dosing by Weight

• Children 7.5-25 kg: use 0.15 mg autoinjector 1
• Children ≥25 kg: use 0.3 mg autoinjector 1, 4
• For infants <7.5 kg, the 0.15 mg autoinjector is still preferable to ampule/syringe methods despite exceeding the 0.01 mg/kg dose, as manual dosing carries 40-fold variation in accuracy and significant delays 2

Intravenous Epinephrine (Reserved for Severe Cases)

• Use IV epinephrine ONLY for cardiac arrest or profound hypotension unresponsive to multiple IM doses and aggressive fluid resuscitation 5, 1, 2
• Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg) given slowly over several minutes 5, 2
• Continuous hemodynamic monitoring is mandatory including ECG, blood pressure every minute, and heart rate 5, 2
• For continuous infusion: add 1 mg epinephrine to 250 mL D5W (4 μg/mL concentration), infuse at 0.1-1.0 μg/kg/min, titrated to effect 5
• Alternative pediatric dosing by "rule of 6": 0.6 × body weight (kg) = mg diluted to 100 mL saline; then 1 mL/h delivers 0.1 μg/kg/min 5

Cardiopulmonary Resuscitation

Initial Dosing

• Newborn infants: 0.01-0.03 mg/kg of 1:10,000 solution IV/IO 5
• Older infants/children: 0.01 mg/kg of 1:10,000 solution (maximum 1 mg) IV/IO, repeated every 3-5 minutes 5, 1

Endotracheal Route (if IV/IO access unavailable)

• Newborn infants: 0.03-0.10 mg/kg of 1:10,000 solution 5
• Older infants/children: 0.1 mg/kg of 1:1000 solution (maximum 10 mg) 5
• Follow with saline flush or dilute in 1-5 mL isotonic saline based on patient size 5

High-Dose Epinephrine Controversy

• High-dose epinephrine (0.1-0.2 mg/kg) is no longer recommended for routine pediatric resuscitation 5
• A multicenter randomized trial found high-dose epinephrine did not improve return of spontaneous circulation, 24-hour survival, discharge survival, or neurological outcomes compared to standard dosing 6
• Multiple studies confirm standard-dose epinephrine is equally effective with potentially fewer adverse effects 6, 7
• High-dose may be considered only in exceptional circumstances such as beta-blocker poisoning 5

Other Indications

Severe Asthma Exacerbation

• 0.01 mg/kg of 1:1000 solution subcutaneously (maximum 0.3-0.5 mg) 5
• May repeat every 20 minutes up to 3 doses 5
• Begin simultaneous treatment with inhaled beta-agonist (albuterol) and corticosteroids 5

Croup (Laryngotracheobronchitis)

• Nebulized: 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 5
• Racemic epinephrine 2.25%: 0.05 mL/kg (maximum 0.5 mL) in 2 mL normal saline 5

Critical Pitfalls to Avoid

• Never delay epinephrine for antihistamines or corticosteroids—delayed administration is associated with fatalities 2
• Never use subcutaneous route for anaphylaxis—IM absorption is 4 times faster 1, 4
• Avoid IV epinephrine without continuous monitoring—several fatalities attributed to injudicious IV use 5
• Do not inject into buttocks, digits, hands, or feet due to risk of tissue necrosis 5, 3
• Avoid repeated injections at the same site due to vasoconstriction-induced tissue necrosis 3
• Use a needle at least 1/2 to 5/8 inch long to ensure intramuscular (not subcutaneous) delivery 3

Special Populations

Patients on Beta-Blockers

• May be unresponsive to epinephrine 5, 2
• Consider glucagon 1-5 mg IV (20-30 μg/kg, maximum 1 mg for children) over 5 minutes, followed by infusion at 5-15 μg/min 5, 2

Refractory Hypotension

• If inadequate response after 10 minutes, double the epinephrine bolus dose 2
• Add dopamine 2-20 μg/kg/min IV infusion, titrated to maintain adequate blood pressure 5
• Consider norepinephrine infusion 0.05-0.5 μg/kg/min for persistent hypotension 2
• Vasopressin 1-2 IU bolus may be considered for refractory cases 2

Post-Administration Monitoring

• Observe in monitored area for minimum 6 hours or until stable and symptoms regressing 2
• Monitor for biphasic reactions, which may occur up to 72 hours later (mean 11 hours) 4
• Prescribe epinephrine autoinjector before discharge with training on recognition and use 2